Person-centred Care Interventions

Person centred care interventions

Having cancer does not mean you are just a set of symptoms to be treated. Cancer can happen to anyone, at any time, regardless of their age, gender, background, or circumstance. Cancer does not discriminate.

Everyone who gets cancer is different. And the care and support they will need to live with a cancer diagnosis in a way that makes sense for their own life, particularly after treatment has finished, will be different.

Thanks to our ever-improving survival rates, more and more people are surviving for longer with or beyond cancer. We are committed to making sure that everybody receives the personalised care and support they need, when they need it, to live a happy and healthy life beyond a diagnosis of cancer.

The Recovery Package is a set of essential interventions designed to deliver a person centred approach to care for people affected by cancer. This includes:

• Holistic Needs Assessment (HNA) and care planning
• Treatment Summary (TS)
• Health and wellbeing events
• Cancer care review (CCR)

The term ‘holism’ comes from a Greek word meaning all, entire or whole. It means taking a top to toe approach, looking at all concerns that the patient and their family may have. Once the concerns are identified, it’s about coming together with a plan of care, called a care plan/ management plan.

In health and wellbeing holism is about considering all physical, social, psychological and spiritual aspects of life, all of which are closely interconnected. A holistic assessment will consider all aspects of a person’s needs and that they are seen as a whole.

Undertaking an holistic needs assessment is not an end in itself. It is a means of ensuring that the person’s concerns or problems are in the first place identified so that attempts can be made to address them. It supports the broader aim of ensuring personalised care that reflects an individual’s health and care needs. An assessment should always result in a care, or action plan.

The assessment process can make a big difference to peoples’ experience of their care. It can help them realise that their concerns are worthy of consideration and not unusual. It opens the door for discussion. It brings to their attention sources of help they may not require there and then but may need at some later point. It may sometimes enable people to seek help at an earlier stage than they might otherwise have done, before the concern or issue has reached more serious proportions.

Part of the benefit of providing such support is to help people with cancer to make choices and to self-manage their condition on a day-to-day basis. This should help to minimise the risk of a crisis which can lead to an emergency or unplanned admission.

A more consistent approach, through holistic needs assessment, of identifying those people whose needs are greatest and/or most immediate, enables teams and organisations to know where best to focus their efforts. It means that resources can be used more effectively and service needs identified.

Finally, it is not a one-off exercise. Holistic needs assessment carried out during the diagnosis and treatment phases should form the basis of assessment and care planning into survivorship or end of life care pathways.

In 2010, a group of Macmillan GP advisers identified key information that would be helpful to them at the end of a patient’s initial cancer treatment. The GPs had been receiving multiple forms of communication from colleagues in secondary care and lacked a simple summary of a patient’s cancer diagnosis, treatment and an ongoing management plan.

To improve this situation, the Treatment Summary template was designed by the National Cancer Survivorship Initiative (NCSI). The Treatment Summary is a document produced by secondary cancer care professionals at the end of treatment and sent to the patient’s GP. It provides important information for GPs, including possible treatment toxicities, information about side effects and/or consequences of treatment, signs and symptoms of a recurrence and any actions for the GP.

It aims to inform GPs and other primary care professionals of any actions they need take and who to contact with any questions or concerns. The patient also receives a copy to improve understanding of their condition and to provide a summary to share with other professionals and those of their choice, eg for travel insurance purposes. A copy of the Treatment Summary in the case notes is also useful for medical staff if the patient is admitted in an emergency after primary treatment is complete.

Informed by the Treatment Summary, the cancer care review is completed by a GP or practice nurse in order to discuss the person’s needs. It is carried out within six months of a cancer diagnosis and covers post-treatment support, financial impact of cancer, patient awareness of prescription exemptions, possible late effects of cancer and cancer treatment and information needs to enable self-management. Some commissioners in England have local incentive schemes to improve quality, timing and/or frequency of the CCR. The cancer care review is also eligible for Quality Outcomes Framework (QO

Health and wellbeing events

We hold two different cancer health and wellbeing events for our cancer patients:

First Steps in cancer care: These are for patients, families and carers who have recently been diagnosed with cancer.

Next steps in cancer care: These are for patients, families and carers who have completed cancer treatment or on continued treatment for cancer.

It is usually a morning session, and we present several working in partnership with other professionals, local services and charities, we aim to provide information about the types of support available locally.

The sessions are open to anyone who has a cancer diagnosis and wants to know what may be available to support them along the way. It is an opportunity to meet the living with and beyond cancer (LWBC) team and ask questions about the issues that may be concerning you.

We provide refreshments and free parking for each session.

If you would like to book a place at one of our events, you can either ask your CNS or contact the LWBC team by phone 01384 456111 ext. 5315 or email dgft.lwbcteam@nhs.net.

Please have a look at our Living with and Beyond Cancer web page for our Health and wellbeing presentation and other useful information, videos and signposting. click here.